~ Insert something interesting here:

Please read and distribute as you see fit…

This past Friday, I went to fill a prescription for Parker as he had an ear infection. Parker’s allergic to penicillin, and he’s often prescribed azithromycin as a substitute. This is the 4th ear infection in his short seven months of existence so Maria and I are quickly becoming experts on detecting, and then treating these. That’s why I was suspicious when the CVS pharmacist directed me to give him eight teaspoons on the first day and then four on the following four days. One teaspoon is equals 5 ml’s. Eight teaspoons is almost an ounce and a half of liquid. His typical bottle feeding is between 3.5 and 4 ounces. The pharmacist was telling me to give this kid a third of a bottle full of this powerful antibiotic.

She knew it seemed odd and she clearly saw the concern on my face because she tried her best to convince me that this is what the doctor prescribed and they new best. She did this while standing 15 feet away as the “pharmacy technician ” (a teenager) bagged the eight bottles of azithromycin and handed me an oral syringe that could choke a horse. This technician was about as helpful as a bagger at a grocery store despite CVS’s instance that they are trained professionals.

Reminder, Parker is 7 months old and they gave me eight bottles, a 10 ml syringe that was as wide as a nickle and as long as my palm, and tried to convince me that the doctor knew best and this was indeed the correct dosage.

My parental instinct was ringing an alarm in my head, and it just didn’t feel right. By now, it was 8pm on a Friday night. I had been in the CVS for thirty minutes while Maria waited in the car with Parker. I took the bag filled with eight bottles of azithromycin and left. When I got home, I called my mother because, again, it just didn’t feel right. She mentioned that she had just seen a segment by Diane Sawyer about pharmacy errors. It was then that I was sure that my kid wasn’t getting eight teaspoons of medicine and that the doctor and I would have a conversation in the morning.

11:30 pm.

I’ve been asleep for an hour and a half when my phone rings. It’s the pharmacist who had filled his prescription. She was frantic and in tears. She asked if I had given Parker the drug and I said that I hadn’t. She paused, collected herself and I could tell she was pulling herself together. She admitted that she had made an error and praised me for being smart enough to know that eight teaspoons was way too much (no shit). She gives me the new dosage amount which I don’t bother to write down because I’m not having this conversation at 11:30 at night and by now I’m totally fuming.

Next morning.

I call the pharmacy, control myself, and explain that there was some confusion last night about the correct dosage, and I just would like to clear things up. I consciously decide to be calm even though I’m shaking with anger at this point. When the pharmacist (a different one) says, “I can’t believe what I’m looking at.” I lose it. For me losing it isn’t really losing it. I’m pretty low-key, don’t like confrontation, and don’t like taking things out on people who aren’t involved with my issues. I am most definitely not and eye-for-an-eye person. I did say that it’s ridiculous that out of the four people behind the counter involved in the conversation the night before, none of them had enough common sense to say that it is ridiculous to give a 7 month old baby 8 teaspoons of anything let alone a fairly powerful antibiotic like azithromycin.

I like to think that we would have known better had this been our first experience with ear infections, however, I think back to when he was 3 months old with his first and I’m not sure. I remember being bleary-eyed and exhausted after 2 night without sleep and a screaming baby. We may not have known that 8 teaspoons is an absurd and potentially lethal amount to give a baby.

I’m not going to crusade against CVS, but I’m not going back to the one here in Groton, MA. I’m not going on a crusade to convince others that they shouldn’t patronize CVS either, but I do want to share my experience. I believe that they’re model promotes quickness and volume over customer safety. A quick google search turn up these two article sin the USA Today (article 1, article 2) confirm that I’m not the only one critical of CVS. I hope that you never have this experience, but if you do, trust your instincts and if you are not comfortable with what a doctor or pharmacists or whomever is telling you, get a second opinion.

So far I’ve had some regional manager filling in for the regular regional manager call me and say he’s sorry over and over again and blame the pharmacist for the error. I’ve also had a woman leave me a voicemail. It sounded like she called from a call center and is only in the office from 9am to 5pm. I know this because her voicemail says so. I returned her call an hour ago. I’m sure she’s busy though and will get back to me today, as long as it is before 5pm. Then I’m sure she’ll get back to me tomorrow. She may have a kid to get home to.

I almost wasn’t able to say that today.

I’m fuming more today than I was before.

—–Update—–

I did get a call from the Customer Service/Advocate at CVS Headquarters and hour and a half after I left a message. It again sounded like she was calling from a call center. It’s pretty hard to take an apology seriously when it’s coming from an, We F’ed Up Call Center.

—-Update—–

So it’s now Tuesday. The woman from the F Up Center said she would “research” someone appropriate to respond to me. That was 23 hours 15 minutes ago.

Still waiting.

In the meantime, we’re in faculty meetings here, and I’ve been able to catch up on some reading. I’m reluctantly reading Seth Godin’s Linchpin. He references an incident with Amazon that occured on a Friday night and they didn’t respond until Monday, “What took so long? On the Internet, 36 Hours in a month.” I would argue that its not just on the Internet, but also in what I consider to be a serious matter like this.

Yeah, pretty scary. The problem occurred in the conversion. For some reason the pharmacist felt it necessary to convert ml to tsp. I’m not sure why because both are listed on the oral syringe. Even the giant horse-choking sized syringe.

It was a good thing this error was so obvious. Kids have died when they were given Methadone instead of Methylin (generic Ritalin). These two drugs are often stored alphabetically so they end up in the wrong bottles.

Thanks, Joe. I’m not sure it would have been that obvious had it happened 5 months prior. We just would have been clueless parents never having been through an ear infection and just wanting to make it better for him.

Thank goodness you and your wife trusted your instincts. Something similarly scary happened to us recently. Not a CVS but an urgent care center doctor that prescribed what my pediatrician felt was inappropriate drug for a 2 year old and furthermore in an excessive dose. The only way I caught it was that the label from the pharmacy (in house Rx) differed from what the doc had verbalized. I have since double checked every dosage we are prescribed with the pharmacists and doc twice over. I will definitely pass this on.

Good job, always double check, and if it seems wrong don’t give it to your child until you are satisfied with all the answers to your questions. Call the answering service for your md. that’s what they are there for. I am a Pharmacy Tech and would never of sold you that medicine. Children are precious and should be treated so, so sorry for your bad experience.

You should file a complaint with the Pharmacy Board. When one of my boys was a baby he was given Zyrtec (allergy med) instead of Zantac (for acid reflux) by Safeway. The label was actually correct with the wrong liquid inside. Luckily for me I knew what Zantac smelled like and smelled it right before I was about to give it to him. I filed a formal complaint with the Pharmacy Board (google for your state) to make sure that it would be addressed with this pharmacy. Thank goodness we both noticed their errors before giving it to our kids.